Factitious disorders and pathological self-harm in a hospital population: an interdisciplinary challenge.

Factitious disorder, Munchausen's Syndrome, and deliberate self-harm have recently been conceptualized as different facets of self-destructive behavior. A descriptive typological classification has been presented by Willenberg et al., but has not yet been tested with a clinical sample. The instrument distinguishes between direct self-harm (e.g., self-inflicted wounds), self-induced disease (e.g., factitious fever), and indirect self-harm delegated to medical staff (e.g., repeated operations occasioned by feigned symptoms). All patients referred to the psychosomatic-psychotherapeutic liaison-consultation service or to the outpatients' department within 14 months (n = 995) and all patients discharged from in-patient psychosomatic-psychotherapeutic treatment within 2 months (n = 62) were assessed. Expert instruction and supervision were provided for the diagnosticians. The assessment was continued for a subsequent year, without special supervision (n = 1,058). Self-destructive behaviors were diagnosed in 7.5% of the cases in the first sample, with certainty (59.5%) or on suspicion (40.5%). In the subsequent sample without supervision, the rate reduced to 3.6%. Referrals had come from almost all clinical departments, including the emergency unit (26%), surgery, internal intensive care, endocrinology (9.5% each), neurology, infectiology, nephrology (7.1% each), dermatology, gastro-enterology, cardiology (4.8% each) and surgical intensive care (2.4%). The occurrence of pathological self-destructive phenomena is underrated when using only the ICD-criteria. The rate is influenced by diagnostic attention.

[Self-destructive behaviour - occurrence and typological classification in an university psychosomatic unit] / Autodestruktives Verhalten - Vorkommen und Typologie in einer universitären psychosomatischen Einrichtung.

The occurrence of self-destructive phenomena (direct self-harm; self-induced disease; self-harm delegated to medical staff) in all patients referred to the psychosomatic consultation service and all outpatients during 14 months and all discharged of the psychosomatic ward during 2 months (N=1057) is determined by the typological-descriptive assessment of Willenberg et al. (1997). Self-destructive behaviour was documented in n=79 cases (7.5%), in 40.5% of these on suspicion. 62% showed recurrent self-harm. In 15% there was a high risk to health, in 4% mortal danger. 51% hurt themselves overtly, 24% secretly. Direct self-harm occurred in 71%, self-induced disease in 48%, delegated self-harm in 35% of the cases (39% overlap). An average of 15 years passes between early precursor symptoms and the reference to the psychosomatic unit. Compared to the control group of psychosomatic patients, self-destructive patients are more often female (81%), younger, less frequently married (statistically confounded with age), more frequently medically certified and sick for more than one year. In sum, they have as many somatic diagnoses (M=0.75) but significantly more psychosocial diagnoses (ICD-10: F) (M=1.86 vs. M=1.40). Bulimia, addiction / substance abuse, and personality disorders proved to be more frequent co-diseases, anxiety disorders were underrepresented. Occurrence and relevance of self-destructive or facticious disorders are apparently underrated, so far. ICD-10 criteria are insufficient to cover all relevant types of self-destructive behaviour.